Nuance, Northamptonshire and NHS Finances….

It may just be me but I often feel the tenor of many of our national debates lacks nuance and subtlety, and as a result the quality of many of those debates doesn’t get us where we need to be. I think it’s time for nuance. And nothing calls more for this than the events of this last weekend.

Today (5th February 2018) we saw a call for NHS funding to be funded by a new hypothecated tax.

Before that we had, on Friday, the story that Northamptonshire County Council’s s151 Officer had issued a section 114 notice. What’s that? Well, it’s bad. It’s BAD. It’s very bad. It basically means a council may not balance its budget and stops all non-statutory spending. The last time this happened was 2001 or 2000 depending on who you ask. And current opinion suggests other councils may be next.

The received wisdom is often that by the time a Council gets to this stage, the Monitoring Officer’s relationship with members may well be untenable. And the structural problem may be so great in today’s financial climate that recovery is uncertain at best. Anyone who cares about public services needs to care about this. Why? Well the Local Government Chronicleseries of reports is a good place to start to understand what should basically be, to borrow NHS jargon, a never event.

When a local authority in these days cannot finance its services, we have the potential that their long term structural funding is unsustainable. Especially if they have been spending their reserves. And while Northamptonshire was severely criticized by an LGA peer challenge of its finances, (which, by the way, demonstrates that Sector Led Improvement is by no means a soft or cosy option for performance improvement) , it would be wrong to assume that this crisis is all Northamptonshire’s fault. This is a systemic issue.

Local Government has been rewarded for making cuts by Central Government, by being given more cuts. Anyone who feels that the cuts in social care have not impacted on the NHS needs only to look at the last three winters to see that this is patently not true. But even Delayed Transfers of Care are not only about money. They need to be about making systems work together better. Meanwhile the Civil Service and NHS are the parts of the public sector which have not actually met the efficiencies expected of them.

This is just storing up trouble. Not least because these cuts impact the people who experience them and the NHS. The reward for failure, it seems, is to have more money poured in, said one commentator last week.

“The government has failed since 2010 to take the decisions required to place local services on a sustainable footing, leaving it to councils to innovate to avoid watching services decline as needs grow…. Haringey LBC, for instance, is seeking to transfer £2bn of assets into a joint venture with a private company because it believes this is the only way estate regeneration can proceed amid austerity and central shackles. Meanwhile, Northamptonshire CC spun out nearly all services in a bid to save £65m (the first of these companies was last week brought back in house). And some districts are borrowing significant sums to invest in property as an investment to fund services.”

How are these connected

These events are connected for several reasons:

In neither the NHS funding debate nor the local government funding debate do we have any nuance about the balance between money and sustainability. In the NHS we seem to have a prevailing discourse of endlessly “pouring more cash in” mode whereas in local government, Governments of several complexions have presided over the development of an entirely foreseeable potential crisis in local services.

If council services go down, so does the NHS. (Winters 2016-18 again anyone?)

The will, the money and the focus on preventing people needing either sets of service is almost entirely absent. This ensures we will – unless we break it – iterate through the demand outpacing resources cycle predicted by Wanless (remember him? He was the one who told us where we’d be today. And as a country we wrote him off as making heroic assumptions about what was possible rather than try to do something to rise to his challenge. And for my money we thereby proved him right. )

The bravery to provoke a rethink

We need to start a rethink. And a hypothecated NHS tax is not, I think, the place to start. Despite support from across the political spectrum. Now I’m not against this idea per se but what I found unhelpful was the breathtakingly naïve and frankly rather throwaway remark from some of the proponents saying “well if we run out of money for the NHS …..” implications being that we can invest yet more or that somehow the public will just be content to ask questions then pour in more cash.

None of this is answer to the issue of secure funding for the NHS. It’s a sideshow. Just pouring more money in hasn’t ever worked. when the NHS experienced a 43% real terms increase in funding at one point under New Labour productivity didn’t keep pace. The NHS has been beset with short term tinkering, with a plethora of people managing different bits of a complex system, creating different and sometimes competing incentives and constrains, and in the process creating ever more byzantine systems within systems.

While there are money issues, the issues in the NHS are not only – in some cases not even primarily – about money. They are about the system not working. We still have functioning and funded CCGs at a time when some STPs are spending as much on project management and governance as their CCGs spend on management salaries put together.

We must refuse to allow the debate on NHS funding to descend into the false dichotomy of “more money” on one side with Governments of all complexions doing what they usually do on the other – rather bland re-statements of investment of £x which sidesteps both the point and the force of the question, and convinces nobody.

Public Health services and councils in financial difficulty

We should also note that we face the possibility in Public Health that councils who are forced to restrict spend to statutory services may find themselves having to fund NHS health checks (which are statutory) while not funding, for example, drugs and alcohol services (which aren’t.) In what kind of world of response to human need and vulnerability do we put NHS healthchecks for the well above services for those at risk of ill-health and death from addiction?

And to add yet more shrill noises about mandating yet more of the public health monies or even worse repeat again the counsel of futility which suggests these things would be better off in the NHS than in local government are entirely the wrong responses here. Neither is the answer here.

The nuance here is to see just how unfit for purpose the approach to mandation of public health services has become, and just how much the DH and national health bodies need to understand better the constitutional and legal nature of local authorities they seek to work with, and work as a system. And once we have considered that, to set about making a system which works.

Getting the debate more real

I’m currently writing a few articles commissioned by journals/magazines on the NHS 70th Birthday. I remember writing about the NHS 60th Birthday. We were in financial crisis then, looking at news articles from ten years ago, the NHS stories of crisis and funding were largely similar – but admittedly less severe than now. Many of them could have been reprinted yesterday with merely a change of names.

The right place to start, for my money, is to realize that these things are all connected and systemic. The wrong thing to do is argue just for yet more money as if that were the only answer.

Money alone is not the answer

Money is a part of the problem, but it is not the whole story. Where the money goes (not just the NHS but social care and housing), how the system is managed (we seem to have created layer upon layer of structure – STPs on tops of CCGs) how the money is spent (systems that work together rather than conflict) are every bit as important. Yes nurses and doctors and many others are overworked massively. Money alone is not going to solve this. And they’re not alone.

But when was the last time equally harassed and overworked social workers, youth workers and housing officers got that kind of attention? Are they not equally important to our society? Yes.

We’ve lionized and totemized the NHS to the point where we can no longer have a nuanced debate about making the system work without being accused of either not caring or wanting to privatize it. We need to pull this debate back into a debate about making our public sector financially sustainable and value for money.

We are still in some places paying extra enhanced payments to primary care for doing stuff which should be part of the core contract. And yet what the NHS calls “avoidable untoward variations in outcomes” for patients remain stubbornly and perennially with us. And more and more community pharmacies – an intensely important aspect of a preventive focused NHS – are heading for insolvency. This is not a system which is working as well as it should. Let’s be honest.

If that’s not enough to convince you, then call to mind the Carter Review, – another of the many national reviews largely distinguished by the lack of any national vim, vigour or vitality behind their implementation – which estimated the NHS could save £5 Billion through efficiencies in productivity alone, or the fact that NHS England commissioned an entirely parallel national diabetes programme which largely bypassed existing prevention infrastructure .

The idea that our health system is working at optimum efficiency and more money is the top priority answer is simply not true. And even if it were, the growth of preventable morbidity and disability means we cannot endlessly continue this cycle of ever greater spend for an ever less healthy population.

So where next?

I believe the answer is not to pour yet more money into the NHS while not properly funding housing or social care. This is false economy. Simply pouring more money in has not delivered what we need from the NHS over the last twenty years, however much we have overworked and understaffed clinicians. The same goes for prevention. We need more upstream preventive measures. They are cheap and value for money.

We need a different approach. For my money here are five starters:

Properly fund social care, housing and prevention (note I say prevention, I’m not making a turf bid here for public health services alone)

Redistribute money around the system so that we join things up

Stop short-term tinkering with the NHS and develop a proper ten year plan which integrates health and social care. Make the financial and commissioning mechanisms follow that. Start by putting one agency in charge not two (NHSE and NHSI)

Invest properly in preventive systems, across the board. This is not about funding public health services. This is about a move to prevention

Make the sector work together

Dear NHS Tax campaigners, if you care about the NHS, you’d better care about local government. Because we’re sunk without each other.